Although spinal surgeries are commonly performed for degenerative lumbar spinal stenosis, herniated intervertebral disk, and cauda equina syndrome, many patients continue to experience pain after surgery. Up to 40% of patients report persistent pain after surgery [1], which may lead to low quality of life, unemployment, and psychological morbidity [2].

Failed back surgery syndrome (FBSS) refers to persistent or recurrent low back pain, with or without sciatica, following spinal surgery, and expected outcomes are not achieved [3]. FBSS has diverse causes, such as recurrent disk herniation, lumbar spinal stenosis, scar adhesion, and lumbar instability [4].

FBSS management encompasses conservative, interventional, and surgical approaches. Conservative treatments, such as medication, physical therapy, and exercise, are commonly employed [3], whereas revision surgery is associated with relatively low success rates, ranging from 22% to 40% [5]. Accordingly, minimally invasive procedures, such as epidural injections, facet joint procedures, and percutaneous and epiduroscopic adhesiolysis, are often preferred for managing pain [6].

Recently, Korean Medicine treatments, including acupotomy, is being increasingly performed for FBSS in clinical practice [7]. However, evidence supporting its therapeutic efficacy remains limited. This report presents a case in which acupotomy, combined with Korean Medicine treatments, resulted in clinical improvements.

1. Case presentation

A 73-year-old female patient with a history of femoral neck fracture and osteoporosis presented with persistent low back pain and radiating pain in both legs, which began in August 2022. In December 2022, she was diagnosed with degenerative lumbar spinal stenosis, lumbar radiculopathy, and degenerative spondylolisthesis (Figs. 1, 2). Despite undergoing open reduction and internal fixation from L2 to L5 in March 2023 (Figs. 3, 4), her symptoms, including stiffness, radiating pain, numbness, hypoesthesia, and weakness, persisted for 8 months. Meanwhile, 8 months of conservative treatments, including physical therapy and medication, did not alleviate her symptoms. As a result, she was admitted to the Spine and Joint Center at Pusan National University Korean Medicine Hospital from November 27, 2023, to December 6, 2023, for further evaluation and management. During her hospitalization, she received Korean Medicine treatments, including acupotomy, sweet bee venom (SBV) pharmacopuncture, electroacupuncture, and herbal medicine. Electronic medical records were used to analyze the patient data.

Figure 1. T2-weighted sagittal magnetic resonance image of the lumbar spine (December 30, 2022).

Figure 2. T2-weighted transverse magnetic resonance images of the lumbar spine (December 30, 2022). (A) L2/L3, (B) L3/L4, and (C) L4/L5.

Figure 3. Sagittal spine (July 24, 2023) computed tomography image of lumbar spine.

Figure 4. Transverse magnetic resonance images of the lumbar spine (March 9, 2023). (A) L2/3, (B) L3/4, and (C) L4/5.

2. Methods

1) Treatment methods

The treatment was administered according to the timeline presented in Table 1.

Table 1 . Treatment timeline.

Length of hospital stay	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7	Day 8	Day 9	Day 10
Acupotomy	+			+				+
Sweet bee venom		+	+		+
Electroacupuncture		+	+		+	+	+		+	+

A '+' symbol denotes the administration of the corresponding treatment on that day..

(1) Acupotomy

Acupotomy was provided on days 1, 4, and 8. Disposable stainless-steel needles, which measured 0.60 × 50 mm or 0.75 × 80 mm (DongBang Acupuncture Inc.), were used. The treatment targeted the bilateral facet joints from L2 to L5 to incise and exfoliate the scar and adhesive tissues around the surgical incision site.

(2) Sweet bee venom pharmacopuncture

The 10% SBV (Kirin Herbal Dispensary) was used, with 1 mL administered on day 2, 1.5 mL on day 3, and 2 mL on day 5. SBV pharmacopuncture was performed at EX-B2 (bilateral sides, L3–L5 level), BL25, BL26, GV3, and GV4.

(3) Electroacupuncture

Disposable stainless-steel needles (0.30 × 50 mm; DongBang Acupuncture Inc.) were used. Electroacupuncture was performed once a day for 15 minutes at EX-B2 (bilateral sides, L3–L5 level) and BL25 and BL26 on days when acupotomy was not performed. Electrodes were placed bilaterally at EX-B2 using an ES-160 device (6 V, 160 mA; ITO Co., Ltd.) with a fixed frequency of 2.0 Hz.

(4) Herbal medicine

The patient received Duhuo Xuduan Tang-gagam (108 g per cheob) with 0.5 cheob 3 times daily, from November 27, 2023, to December 6, 2023 (Table 2).

Table 2 . Prescription of the Duhuo Xuduan Tang-gagam decoction.

Herbal medicine component	Amounts (g) per pack (cheob)	Herbal medicine component	Amounts (g) per pack (cheob)
Lonicerae flos	12	Rehmanniae radix preparata	4
Forsythiae fructus	12	Cnidii rhizoma	4
Araliae continentalis radix	6	Poria	4
Notopterygii rhizoma et radix	6	Achyranthis radix	4
Angelicae radix	6	Eucommiae cortex	4
Paeoniae radix alba	6	Gentianae macrophyllae radix	4
Salviae miltiorrhizae radix	6	Asari radix et rhizoma	4
Clematidis radix et rhizoma	6	Saposhnikoviae radix	4
Astragali radix	6	Cinnamomi cortex	4
Dipsaci radix	4	Glycyrrhizae radix et rhizoma	2

2) Evaluation methods

(1) Numeric rating scale

The intensity of both low back pain and radiating pain was recorded daily on a scale of 1 to 10.

(2) Visual analog scale

The patient marked the pain intensity on the 100-mm line on admission and discharge.

(3) Lumbar range of motion

Lumbar range of motions (ROMs) in flexion, extension, lateral flexion, and rotation were measured on admission and discharge.

(4) Oswestry disability index

This tool originally consisted of 10 items, including sexual activity [8]. In this study, sexual activity was excluded, so 9 items were assessed. Each item was scored from 0 to 5, with a maximum total score of 45 on admission and discharge.

(5) Other observations

The durations of the standing balance on admission and discharge were evaluated to assess functional performance.

3) Evaluation results

The numeric rating scale (NRS) score for low back pain decreased from 7 to 3, and radiating pain decreased from 6 to 3 (Fig. 5). The visual analog scale (VAS) score decreased from 7.0 to 2.6. Regarding ROM, no changes were noted in flexion and rotation, which were already within the normal limits. However, extension and lateral flexion ROM increased from 15° to 30°, reaching within normal limits (Fig. 6). The Oswestry disability index (ODI) decreased from 55.6% to 20.0%, indicating a change from severe to minimal disability [9]. The duration of standing balance increased from 10 to 20 minutes.

Figure 5. Daily follow-ups of the change in NRS. NRS, numeric rating scale.

Figure 6. Changes in the ROM after treatment. ROM, range of motion.

After 10 days of combined Korean Medicine treatment including acupotomy, the patient’s chronic pain, which had persisted for 8 months, improved, as evidenced by reductions in NRS and VAS scores: low back pain NRS score decreased from 7 to 3, radiating pain NRS score from 6 to 3, and VAS score from 7.0 to 2.6. In addition, the patient’s lumbar ROM returned to within the normal limit, the ODI score dropped from severe (55.6%) to minimal disability (20%), and the standing balance duration improved from 10 to 20 seconds.

The improvement in pain intensity can be attributed to the mechanism of acupotomy, which involves incising and exfoliating the scar and adhesive tissues. Epidural fibrosis refers to fibrotic adhesions that occur in the epidural space because of surgical trauma and inflammation [10]. It is presents in 20–36% of FBSS cases and is often associated with radicular pain and poor clinical outcomes [11]. In this case, acupotomy effectively alleviated the pain that persisted despite 8 months of conservative treatments, which was likely due to its physical stimulation of the target tissue. SBV pharmacoacupuncture and electroacupuncture were also employed; however, they mainly stimulated the relatively superficial layer of the lumbar region. Conversely, acupotomy was applied to deeper layers and directly stimulated the target tissue, such as the scar tissue or adherent target tissue. Therefore, acupotomy was considered to have contributed more to the improvement of fibrosis around the nerve roots and epidural space. In addition, the combination treatment may lead to an improvement in ROM and functional disability by reducing pain intensity and stiffness [12]. The decrease in ODI indicates a shift from a level of disability where pain significantly interferes with daily activities to a level where most daily activities are manageable and do not require further treatment [9]. The improvement in standing balance suggests that the patient can perform daily activities more effectively.

Postoperative imaging (Fig. 4) revealed no recurrence of a herniated intervertebral disk or worsening stenosis. In addition, acupotomy alleviated symptoms that had not improved with conservative treatments. This proposes that the scar tissue and adhesions may have been the primary cause of the patient’s symptoms. Scar adhesions can contract and exert tension on the dura mater and nerve roots, increasing sensitivity to mechanical pressure and resulting in various symptoms [13]. Acupotomy using thick and flat needles for intense stimulation of the local area can relieve blood flow disturbances surrounding the nerve [14]. Conversely, revision surgery has a low success rate of 35% and may be associated with certain surgical complications [15]. Compared with revision surgery, acupotomy can incise and exfoliate scar tissue and adhesions, reducing mechanical pressure and improving blood circulation, which in turn decreases nerve irritation. Li [16] used a rabbit model and showed that acupotomy effectively regulated the levels of basic fibroblast growth factor and CD34 in the serum and muscle tissue while promoting local tissue revascularization. Acupotomy is also a relatively simple procedure, which takes only 10–15 minutes, is easy to perform, and allows for quick recovery, enabling patients to resume their daily activities almost immediately [17].

In the study by Woo and Cho [18], 6 acupotomy sessions were performed with pharmacoacupuncture, cupping therapy, and physical therapy, which decreased the NRS score from 10 to 2. In the present case, 3 sessions of acupotomy alongside other treatments led not only to a reduction in pain intensity but also to increased functional disability. This case may reflect more pronounced short-term effects. Similarly, Du et al. [19] reported that percutaneous transforaminal endoscopic discectomy combined with acupotomy improved VAS, Japanese Orthopaedic Association, and ODI scores in patients with FBSS, without serious complications. Despite growing evidence on the therapeutic benefits of combining acupotomy with other treatments, current evidence remains limited.

This study has several limitations. First, the report of a single case without a control group hinders the generalizability of the findings to all patients with FBSS. Second, the individual effectiveness of each treatment method cannot be isolated and assessed. Lastly, the absence of follow-up evaluations after discharge poses challenges in determining the sustained effects of the treatment. Nevertheless, this case highlights the therapeutic effects of acupotomy with Korean Medicine treatments for FBSS. Further research is needed to explore the synergistic effects of acupotomy in treating FBSS.

This work was supported by a 2-Year Research Grant from Pusan National University.

Conceptualization: HH, SKA, EK. Formal analysis: HH, TL. Project administration: EK. Supervision: EK. Visualization: HH. Writing – original draft: HH, JK. Writing – review & editing: JK, EK.

The authors have no conflicts of interest to declare.

None.

The Institutional Review Board of Pusan National University Korean Medicine Hospital approved this study (PNUKH IRB 2024-09-005). Written informed consent was obtained from the patient before the study participation.